Waitemata DHB has admitted failings that may have led to the death of an elderly man in a secure ward at Auckland's North Shore Hospital.
The admission came as the Government announced an inquiry into all aspects of New Zealand's mental health system.
Donald Morey, 71, was placed in the Older Adults' Mental Health Unit after his daughters could no longer care for him.
Kelly Wilson, 45, and Deborah Hussey, 43, say their dad was a caring, loving father and grandfather, but was plunged into depression after the death of his wife four years ago.
The previously fit, healthy and social Morey had attempted suicide in 1993, but since then appeared happy and well.
When he became depressed again, they sought help - first from his GP, then from a counsellor, and finally, struggling to care for him at home, a desperate Wilson contacted Morey's psychologist.
Morey was put into the secure Ward 12 at North Shore Hospital, with patients who had a variety of mental health problems.
The family thought the ward was unsuitable for their father, but their worst fear was that he would kill himself and they thought he would be safe in the ward.
"We thought we'd have him out within six weeks and he'd be Dad again," Hussey said. "We had faith that they knew what they were doing and that he would be better."
Instead, within days Morey became "psychotic" and paranoid. Sectioned by the DHB, he was put on 24/7 arm's-length suicide watch on October 2.
By October 10 he seemed to be improving and at 10am that day he was moved off the 24/7 watch, with staff instructed to check on him every 10 minutes.
Yet that afternoon Morey was left alone for 30 minutes between 2.40pm and 3.10pm, and again between 3.34pm and 3.58pm. At 3.58pm he was found dead.
At 4.05pm a staff member called the telephone switchboard, but the call was interpreted as a request for security, not a life-support team. At 4.13pm staff called for emergency medical staff, who arrived at 4.20pm. Morey could not be resuscitated.
His death has been referred to the coroner, who has made an initial finding of suspected suicide.
Hussey had been to see her dad that morning. He was playing cards with other patients when the nurse told him he was coming off the 24-7 watch.
"I went outside with Dad to say, 'Look, I have to go now', and he told me - I think it was that day or the day before - 'Remember I love you all'. Then I went home. Then [Kelly] got the phone call."
Wilson alternated between disbelief and rage when the head of the ER called around 4.30pm. "She said, 'There's no easy way to say this but your father's dead'. I said, 'What do you mean he's dead? He's in bloody hospital, being looked after'.
"I went in and I was screaming down the ward, 'Where the f*** is my father? Where is he? How can this happen?' They had him lying in his room."
She sat on the floor next to him, debating when to call Hussey.
"It was the worst day of my life. I still have nightmares."
In the months since their father's death, the pair were reluctant to blame DHB staff - until a December meeting when staff admitted checks had been missed.
In a letter on December 20, head of division John Scott confirmed the missed checks and the failure to call the life support team.
The DHB told the Herald it had extended its condolences and was in touch with Morey's family and offering support. External and internal inquiries are under way.
Wilson said she's happy with the work the DHB is doing so far, and they don't want "further guilt" to be laid on the staff involved.
"But it is still not good enough - because we lost our dad and are still really suffering from that," she said.
The pair want to raise awareness of the lack of resources, as well as how few facilities there are for people with depression, and a lack of focus on older people's mental health.
Although the full terms of the newly announced mental health inquiry make little mention of the elderly, a spokesperson from the office of Health Minister David Clark said the terms of reference for the inquiry were broad and cover "all age groups, including older people".
Older men have one of the highest rates of suicide in New Zealand, according to old-age psychiatrist Dr Gary Cheung.
Although about a third of older people who commit suicide are diagnosed with depression, it often goes undetected in older men who tend not to talk about mental health, Cheung said.
Doctors need more resources and training to pick up on elder-specific risk factors, he said.
WHERE TO GET HELP:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call police immediately on 111.
OR IF YOU NEED TO TALK TO SOMEONE ELSE:
• NEED TO TALK? Free call or text 1737 any time for support from a trained counsellor • LIFELINE: 0800 543 354 (available 24/7) • SUICIDE CRISIS HELPLINE: 0508 828 865 (0508 TAUTOKO) (available 24/7) • YOUTHLINE: 0800 376 633 • NEED TO TALK? Free call or text 1737 (available 24/7) • KIDSLINE: 0800 543 754 (available 24/7) • WHATSUP: 0800 942 8787 (1pm to 11pm) • DEPRESSION HELPLINE: 0800 111 757